RN First Call Certified Practice

Adult Decision Support Tools: GASTROINTESTINAL GENTIOURINARY

ASSESSMENT

This assessment is based on best practice as of February 2012. For more information or to provide feedback on this or any other decision support tools, e-mail certifiedpractice@crnbc.ca

ADULT GASTROINTESTINAL (GI) GENITOURINARY (GU) ASSESSMENT

The following assessment must be completed and documented.

ASSESSMENT
History of Present Illness and Review of Systems General The following characteristics of each symptom should be elicited and explored: Onset (sudden or gradual) Location Duration, chronology Characteristics/quality of symptom Associated symptoms Precipitating and aggravating factors Relieving factors Timing, frequency, and duration Current situation (same, improving or deteriorating) Previous diagnosis of similar episodes Previous treatments and efficacy Effects on daily activities Cardinal Signs and Symptoms In addition to the general characteristics outlined above, additional characteristics of specific symptoms should be elicited, as follows: Abdominal Pain Quality sharp, burning, cramping Quantity constant, intermittent Radiation localized, generalized Timing related to eating or movement Severity Consider GU indicators flank, suprapubic, genital, groin or low back pain and CostoVertebral Angle (CVA) tenderness Nausea and Vomiting Frequency, amount
CRNBC monitors and revises the CRNBC certified practice decision support tools (DSTs) every two years and as necessary based on best practices. The information provided in the DSTs is considered current as of the date of publication. CRNBC-certified nurses (RN(C)s) are responsible for ensuring they refer to the most current DSTs. The DSTs are not intended to replace the RN(C)'s professional responsibility to exercise independent clinical judgment and use evidence to support competent, ethical care. The RN(C) must consult with or refer to a physician or nurse practitioner as appropriate, or whenever a course of action deviates from the DST. THIS DST IS FOR USE BY REGISTERED NURSES CERTIFIED BY CRNBC

CRNBC May 2012/Pub. 684

RN First Call Certified Practice

Adult Decision Support Tools: GASTROINTESTINAL GENTIOURINARY

ASSESSMENT

Presence of bile Hematemesis Force Colour Relationship to food intake

Dysphagia Solids or liquids Site where food gets stuck Food is regurgitated Bowel Habits Last bowel movement Frequency, color and consistency of stool Presence of blood or melena Pain before, during or after defecation Sense of incomplete emptying after bowel movement Use of laxatives type and frequency Tenesmus Hemorrhoids Belching, bloating and flatulence Change in bowel habits Urinary symptoms Frequency, urgency, quantity Dysuria and its timing during voiding (at beginning or end, throughout) Difficulty in starting or stopping urinary stream Change in colour and odour of urine Hematuria Incontinence (including urge and stress) Presence of stones or sediment in the urine Nocturia (new onset or increase in usual pattern) Urinary retention Jaundice Scleral icterus Tea-coloured urine Clay-coloured bowel movements Pruritis (itching) History of hepatitis A, hepatitis B or hepatitis C GU - Female Where appropriate for females to rule out ectopic, Pelvic Inflammatory Disease (PID) or pregnancy as the cause of symptoms: Date of Last Menstrual Period (LMP) any changes? Dyspareunia or post coital bleeding Lesions on external genitalia
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CRNBC May 2012/Pub. 684

RN First Call Certified Practice

Adult Decision Support Tools: GASTROINTESTINAL GENTIOURINARY

ASSESSMENT

Itching Urethral or vaginal discharge Sense of pelvic relaxation (pelvic organs feel as though they are falling down or out)

Other Associated Symptoms Change in appetite Fever Malaise Headache Dehydration Meal pattern Recent weight loss or gain that is not deliberate Enlarged, painful nodes (axilla, groin) Skin (dry, rash, itchy) History Specific to GI and GU Systems Allergies (seasonal as well as reactions) Past and current use of medications: prescription and Over The Counter (OTC) e.g., Acetyl Salicylate Acid (ASA), antacids, triple therapy for peptic ulcer disease, acetaminophen, antibiotics, laxatives, estrogen, progesterone (including contraceptive management), anticholinergics, antihypertensives, anti-psychotics, thiazide diuretics, immuno-suppressants, digoxin, codeine Herbal preparations and traditional therapies Immunizations Diseases - GI: - Hiatus hernia, oesophageal cancer - Documented H. pylori or Gastro Esophageal Reflux Disease (GERD) - Presence of hernia, masses - Chronic constipation - Irritable Bowel Syndrome (IBS), Inflammatory Bowel Disease (IBD) - Peptic ulcer disease (PUD) - Diverticulosis - Liver disease (hepatitis A, hepatitis B, hepatitis C or cirrhosis), gall bladder disease - Pancreatitis - Diabetes mellitus Diseases GU: - Human Papilloma Virus (HPV), Sexually Transmitted Infections (STIs), including Human Immunodeficiency Virus (HIV) - Renal disease, pyelonephritis, recurrent cystitis, renal stones - Congenital structural abnormalities of GU tract - Female: PID Females: - Menstrual history menarche, LMP, interval, regularity, duration and amount of flow, Premenstrual symptoms (PMS), dysmenorrhea, menopause, postmenopausal bleeding. - Obstetrical history Gravida, Term, Para, Abortion, Live (GTPAL) stillbirths, complications during pregnancies, deliveries, infertility
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CRNBC May 2012/Pub. 684

RN First Call Certified Practice

Adult Decision Support Tools: GASTROINTESTINAL GENTIOURINARY

ASSESSMENT

Other: - Abdominal surgery or exams, including GU such as catheterization, gynaecological procedures - Blood transfusion - Immunocompromised Family History Specific to GI GU Systems Household contact with hepatitis A or hepatitis B Household contact with recent GI infections Food poisoning GERD PUD Gallbladder disease Gastric or colon cancer Polyps Pancreatitis Metabolic disease (i.e., diabetes mellitus, porphyria) Cardiac disease Renal disease (e.g., renal cancer, polycystic kidneys, renal stones) Urinary tract infections Personal and social history (specific to GI - GU systems) Substance use alcohol, smoking, caffeine, street drugs, including injection drugs, steroids, dietary recall including foods avoided (and reasons for), fat intake, nitrate intake (e.g., smoked foods) Obesity, anorexia, bulimia or other eating disorder Travel to area where infectious GI conditions are endemic Body piercing or tattoos Stress at work, home or school Quality of drinking water - exposure to pollutants Sanitation problems at home or in the community Personal hygiene, toileting habits, use of bubble bath, douches, tight-fitting underwear or other clothing Sexual history and practices, including risk behaviours (unprotected oral, anal or vaginal intercourse, multiple partners, sexual orientation) and contraceptives Symptomatic sexual partner Sexual or physical assault or spousal abuse Fear, embarrassment, anxiety Missing work, school or social functions because of GU symptoms (e.g., incontinence) Occupational or School Environment Healthcare occupation Institutional environmentworkers or residents Environmental exposure Chemical exposure

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RN First Call Certified Practice

Adult Decision Support Tools: GASTROINTESTINAL GENTIOURINARY

ASSESSMENT

PHYSICAL ASSESSMENT
Vital Signs Temperature Pulse Respiratory rate SpO2 Blood Pressure General Apparent state of health Appearance of comfort or distress Color, nutritional status State of hydration Match between appearance and stated age Abdominal Inspection Abdominal contour, symmetry, scars, dilatation of veins Movement of abdominal wall with respiration Visible masses, hernias, pulsations, peristalsis Guarding and positioning for comfort Ability to mobilize and gait Auscultation Auscultation should be performed before percussion and palpation so as not to alter bowel sounds Presence, character and frequency of bowel sounds Presence of bruits (renal, iliac or abdominal aortic) Percussion Percuss resonance, tympany, dull, flat Liver: define upper and lower borders, measure span Spleen: confirm presence of normal resonance over lowest rib interspace in anterior axillary line Bladder: identify distension and fullness CVA percussion for tenderness Palpation Palpation is performed with the patient lying supine, with hands by the sides and relaxed The patient's abdomen must be completely exposed Examine all four quadrants in succession Start with the painless areas, and palpate the painful area last Light Palpation (perform first) Tenderness, muscle guarding, rigidity Superficial organs or masses

THIS DST IS FOR USE BY REGISTERED NURSES CERTIFIED BY CRNBC

CRNBC May 2012/Pub. 684

RN First Call Certified Practice

Adult Decision Support Tools: GASTROINTESTINAL GENTIOURINARY

ASSESSMENT

Deep Palpation (be careful not to rupture an organ or mass), assess for abdominal guarding, tenderness or rigid abdomen Feel for organs: - Liver assess size, tenderness, smooth or irregular border, firmness or hardness - Spleen assess for enlargement, tenderness, consistency - Kidney assess for tenderness, enlargement - Bladder assess for distension, tenderness Masses: location, size, shape, mobility, tenderness, movement with respiration, pulsation, hernias (midline, incisional, groin) Assess for rebound tenderness (pain that occurs upon suddenly releasing the hand after deep palpation), which indicates peritoneal irritation Assess for referred tenderness (pain that is felt in an area distant to the area being palpated), which can be a clue to the location of the underlying disease Inguinal and femoral lymph nodes: enlargement, tenderness Femoral pulses

Abdominal examination: peripheral areas Jaundice Spider nevi on face, neck or upper trunk, palmar erythema, Dupuytrens contracture, clubbing of fingers GU System Female Inspection External genitalia: labia majora and labia minora: lesions, ulcerations, masses, induration, and areas of different colour, hair distribution Perineum: lesions, ulcerations, masses, induration, scars Clitoris: size, lesions, ulcerations Urethra: discharge, lesions, ulcerations Vagina: speculum exam- inflammation, atrophy, discharge, lesions, ulcerations, masses, induration, nodularity, relaxation of perineum (ask client to bear down and observe for any bulging of vaginal walls) Cervix: speculum exam position, color, shape, size, consistency discharge, erosions, ulcerations Os: multipara or nullipara Palpation Skenes and Bartholins glands: masses, discharge, tenderness Cervix: cervical tenderness, bleeding after contact, consistency of cervical tissue (normal cervix is pink and feels firm, like the tip of the nose; in pregnancy, the cervix is bluish and feels softer, like the lips of the mouth) Uterus: position, size, contour, consistency of uterine tissue, mobility on movement Adnexa: ovaries for tenderness, masses, consistency, contour, mobility, pain on movement (Chandeliers sign) Rectal Examination For occult blood (which would indicate GI bleeding)
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CRNBC May 2012/Pub. 684

RN First Call Certified Practice

Adult Decision Support Tools: GASTROINTESTINAL GENTIOURINARY

ASSESSMENT

For referred pain (which occurs in appendicitis) For masses, haemorrhoids, anal fissures, sphincter tone, etc.

Associated Systems Cardiovascular and Pulmonary Examination A cardiovascular and pulmonary exam should also be performed Eyes, ears, nose, throat Assess for pharyngitis and conjunctivitis (chlamydial infection, gonorrhea) Lymph nodes (auricular, tonsillar, submandibular, supraclavicular, infraclavicular) Integumentary Assess for skin lesions, rashes, polyarthralgias of systemic gonorrhea and hydration status

SYMPTOMS REQUIRING URGENT REFERRAL

The first step is to identify those patients which require urgent referral. The following GI signs and symptoms require immediate referral to a physician or nurse practitioner: Severe dehydration (elderly) Uncontrolled vomiting Recurrent fevers Haematemesis Frank rectal bleeding or perianal fissures or ulcers Melena Hematochezia Immunocompromised patients (HIV, diabetes, patient taking steroids) Jaundice Ascites Distended abdomen Rigid painful abdomen (also consider PID, ectopic pregnancy) Abdominal bruit or pulsating masses Organomegaly Tachycardia and lung crackles Localized abdominal pain Altered peripheral pulse Unequal BP left to right (difference of approximately 30 mm Hg is indicator of aortic aneurysm) Joint edema, erythema, warmth The following GU signs and symptoms require immediate referral to a physician or nurse practitioner: Bleeding from the urethra Urinary retention

THIS DST IS FOR USE BY REGISTERED NURSES CERTIFIED BY CRNBC

CRNBC May 2012/Pub. 684

RN First Call Certified Practice

Adult Decision Support Tools: GASTROINTESTINAL GENTIOURINARY

ASSESSMENT

Urethral discharge Severe GU pain (consider PID or ectopic pregnancy) Systemic symptoms (sepsis) Incontinence (new onset) Recent urologic/renal surgery Treatment failure after 3 days

Note: The certified practice nurse may consider the following diagnostic tests in the examination of the GI/GU system to support clinical decision making: Stool for occult blood Stool for Ova and Parasites (O&P), Culture and Sensitivity (C&S) Haemoglobin Pregnancy test Pap smear Urinalysis dipstick, R&M, C&S C&S urethral discharge, prostatic secretions, vaginal discharge Swabs for STIs Random Blood Glucose (RBG) Electrocardiogram (ECG)

REFERENCES
Beers, M., Porter, R., Jones. T., Kaplain, J., & M. Berkwits. (Eds.). (2006). Merck Manual of Diagnosis and Therapy. (18th Ed.) Retrieved September 25, 2009 from http://online.statref.com/Document/Document.aspx?docAddress=gb7MLSmlKTVwr5-Sca3wA%3d%3d&Scroll=15&Index=2&SessionId=103ECB0NRBQVXIUX Buss, J. (Ed.) (2011). Health Assessment Made Incredibly Visual! (2nd Ed.) Ambler, PA: Lippincott, Williams and Wilkins. Estes, Mary Ellen Zator. (2010). Health Assessment & Physical Assessment, 4th Ed. Clifton Park, NY: Delmare, Cengage Learning. Jarvis, C. (2009). Physical Examination & Health Assessment First Canadian Edition (Browne, A., MacDonald-Jenkins, J., & Luctkar-Flude, M. Eds.). Toronto, Canada: Elsevier Canada. Stephen, T., Skillen, D., Day, R., & L. Bickley. (2010). Canadian Bates Guide to Health Assessment for Nurses. Philadelphia, PA: Lippincott, Williams and Wilkins.

THIS DST IS FOR USE BY REGISTERED NURSES CERTIFIED BY CRNBC

CRNBC May 2012/Pub. 684